WOUND

CLASSIFICATION AND
MANAGEMENT
 Definition
Classification
OUTLIN Healing
E Wound Care
Reconstructive Ladder
WOUND

A break in the integrity of the skin or tissues often which may be

associated with disruption of structure and function
(SRB’s Manual of Surgery)

A loss of continuity of the skin or mucous membrane, which may

involve soft tissues, muscle, bone and other anatomical structures
(M Collier)
CLASSIFICATION OF WOUND

Acute vs Chronic
Tidy vs Untidy
Depth
Morphology
Degree of Contamination of
Surgical Wound
CLASSIFICATION OF WOUND

Acute • Heals in an anticipated time frame

• Immediate to several weeks
Wound • Result of trauma or surgery

• Fails to heal in the expected time for a wound of

Chronic that type (around 3 - 4 weeks)
• Delays most commonly occur in the inflammatory
Wound phase
• Pressure ulcer, diabetic ulcer
CLASSIFICATION OF WOUND

Tidy Wound Untidy Wound

Inflicted by sharp instruments Results from tearing, crushing,

No devitalized tissue avulsion
Usually single and clean cut Contains devitalized tissue
Skin wound often multiple and
irregular
CLASSIFICATION OF WOUND
Partial Full
Superfici
Thicknes Thicknes Epidermis,
al Wound
Only s Epidermis & s dermis,
epidermis dermis are subcutaneous
affected affected tissue are
involved
Bleed on injury,
Fatty tissue,
blood clot will
Heals within bones, muscle
cover the
days wound –scar
may also be
damage
formation

Several days to
E.g. abrasion Several months
several weeks
and blister to heal
to heals
CLASSIFICATION OF WOUND
• Abrasion
• Shearing injury of skin
• Most are superficial, will heal by
epithelialization
• Laceration
• Irregular tear in the skin, produced by
overstretching
• May be linear/stellate
CLASSIFICATION OF WOUND
• Bruise/Contusion
• Caused by blunt force
• Damages small blood vessels, causes
interstitial bleeding
• No disruption of continuity of tissue

• Haematoma
• Amount of bleeding sufficient to cause
localized swelling
CLASSIFICATION OF WOUND
• Puncture Wound
• Open injury in which foreign materials
and organisms are carried deeply into
underlying tissue
• Bite
• Puncture wound caused by
animal/human bites
• Associated with high incidence of
infection (from oral cavity flora)
CLASSIFICATION OF WOUND
• Degloving
• Skin and subcutaneous fat are stripped by
avulsion from underlying fascia
• Neurovascular structures, tendon or bone
exposed
• Crush Injury
• Variant of blunt injury
• Accompanied by degloving and
compartment syndrome
 CLASSIFICATION OF WOUND
Surgical wound classification (based on degree of contamination/
susceptibility to infection):

CLEAN –
CONTAMINATE
CLEAN CONTAMINATE DIRTY
D
(Class I) D (Class IV)
(Class III)
(Class II)
CLASSIFICATION OF WOUND
CLEAN
(Class I)
• Uninfected operative wound
• No inflammation encountered
• Respiratory/alimentary/genital or
uninfected urinary tract not entered
• May be primarily closed
• E.g. incisional/excisional biopsy of lymph
node, thyroidectomy
CLASSIFICATION OF WOUND
CLEAN – CONTAMINATED
(Class II)
• Respiratory/alimentary/genital or urinary
tracts are entered under controlled
conditions
• Includes biliary tract, appendix, vagina,
oropharynx
• No evidence of infection
• No major break in sterile technique
• E.g. tonsillectomy, sinus surgery, head
and neck surgery with spillage from
alimentary/respiratory tract
CLASSIFICATION OF WOUND
CONTAMINATED
(Class III)
• Open, fresh wounds
• Operation with major break in sterile
techniques
• Gross spillage from GI tract
• Acute inflammation encountered
• E.g. gunshot wound
CLASSIFICATION OF WOUND
DIRTY
(Class IV)
• Old traumatic wounds with retained
devitalized tissue
• Involve existing clinical infection or
perforated viscera
• Suggests presence of organisms causing
post-op infection before operation
• E.g. incision and drainage of abscess
WOUND
HEALING
• A wound is ‘healed’ when:
• Connective tissue repair
and complete re-
epithelialization have
occurred
• Skin cover has been
resorted with scar tissue
without the necessity of
drains or dressings
WOUND
CARE
WOUND CARE
For wound to heal and progress through the stages of wound
healing, the wound bed needs to be:

Well Free of
Clear of
Vascularise
Infection
Devitalise Moist
d d Tissue
 WOUND CARE
T I M E
Infection or
Tissue Moisture Epidermal Margin
Inflammation
• Viable vs non- • Heat, erythema, • Exudate level: dry, • Advancing vs non-
viable tissue pain, oedema, minimal, advancing
• Viable: purulent discharge moderate, wet • Rolled, thickened,
granulating, undermined
epithelium
• Non-viable:
slough / necrotic
WOUND CARE
• Benefits of moist wound healing:
• Faster wound healing
• Promotes epithelialization
• Retention of growth factor at wound
site (acute wound fluid is rich in
growth factors)
• Less prominent scar formation
• Reduced time to eliminate scabs
RECONSTRUCTIVE LADDER

• Originates from the ‘Wound-Closure Ladder’

• Stepwise algorithm, graduated approach
• Mandates starting with the simplest, least
complex closure possibility and progressing
up the ladder only when required
RECONSTRUCTIVE LADDER
RECONSTRUCTIVE ELEVATOR

• The reconstructive elevator implies that in

the era of form and function, simplest is not
necessarily always best
• May skip a rung of the ladder and take the
elevator up to the desired floor
SECONDARY INTENTION
• Occurs in the wound that is left open
• Heal by granulation, contraction & epithelialisation
• Increased inflammation & proliferation
• Poor scar
PRIMARY INTENTION

• Wound edges well opposed

• Epithelial regeneration with minimal
scarring
• Because of minimal surrounding tissue
trauma, it causes the least inflammation
& leaves the best scar
• E.g. well-opposed surgical incisions
DELAYED PRIMARY CLOSURE
(TERTIARY INTENTION)

• Delayed primary intention healing

• Occurs when the wound edges are not opposed
immediately, which may be necessary in contaminated /
untidy wounds
• The inflammatory & proliferative phases of healing have
become well advanced when closure of the wound is
carried out
• Result in a less satisfactory scar than after healing by
primary intention
SKIN GRAFTS
• Grafts are tissues that are transferred
without their blood supply
• Skin grafts can be split-thickness, full-
thickness or composite
Factors Affecting Graft Take
Vascularisation of donor site
Blood supply of wound bed
Immobility and contact with wound bed
Presence of haematoma/seroma
Infection
Systemic factors
SKIN GRAFTS
SSG FTSG
More likely to take Higher risk of graft loss
Contracts more Contracts less
Pigment abnormal Better colour match
Susceptible to trauma once heal More robust once healed
Limited sensory recovery Better sensory recovery
Slow donor site healing by re- Fast donor site healing by primary
epithelialization intention
Large volumes can be harvested Limited availability of donor skin
SKIN GRAFTS
SKIN GRAFT
• Haemostasis
• Prevents excessive bleeding
following grafting
• Plasmatic Imbibition
• Days 1 -2: fluid migrates into
graft bed
• Inosculation
• Days 2 -3: vascular network
establishes
• Re-innervation
• Weeks 2 – 4:
TISSUE EXPANSION
• Using ‘local’ tissue for reconstruction
• Involves placing a device – usually an expandable
balloon constructed from silicone – beneath the tissue
to be expanded – progressively enlarging the volume
with fluid - the overlying tissue accommodates to the
changed vascular pressure
• Tissues expanded do not hypertrophy, but there are
major changes in the collagen structure
• Must never be used under irradiated tissues (such as
mastectomy sites), which will not expand but necrose
• Also contraindicated in infection and underneath skin
grafted areas
TISSUE EXPANSION

ADVANTAGES DISADVANTAGES

- Reconstructed tissue is of - Painful

similar colour and texture - Prolonged
- Well vascularised tissue - Multiple procedures and clinic
- Sensate skin visits
- Limited morbidity - Cost of device high
God hears every unspoken word,
sees every unseen wound, and
heals every unbearable pain.